Traumatic stress is found in many competent, healthy, strong, good people.
No one can completely protect themselves from traumatic experiences.
Many people have long-lasting problems following exposure to trauma.
Up to 8% of persons will have PTSD at some time in their lives. People who
react to traumas are not going crazy. What is happening to them is
part of a set of common symptoms and problems that are connected with being
in a traumatic situation, and thus, is a normal reaction to abnormal events
and experiences. Having symptoms after a traumatic event is
NOT a sign of personal weakness. Given exposure to a trauma that is
bad enough, probably all people would develop PTSD.

By understanding trauma
symptoms better, a person can become less fearful of them and better able to
manage them. By recognizing the effects of trauma and knowing more about
symptoms, a person will be better able to decide about getting treatment.

_______________________

PTSD, DID, and EMDR

Posttraumatic Stress Disorder

"The essential feature of Posttraumatic Stress Disorder us the development of characteristic symptoms following exposure to an extreme traumatic stressor involving direct personal experience of an event that involves actual or threatened death or serious injury, or other threat to one's physical integrity; or witnessing an event that involves death, injury, or a threat to the physical integrity of another person; or learning about unexpected or violent death, serious harm, or threat of death or injury experienced by a family member or other close associate (Criteria A1). The person's response to the event must involve intense fear, helplessness, or horror (or in children, the response must involve disorganized or agitated behavior) (Criterion A2). The characteristic symptoms resulting from the exposure to the extreme trauma include persistent reexperiencing of the traumatic event (Criterion E), and the disturbance must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning (Criterion F).

Traumatic events that are experienced directly include, but are not limited to, military combat, violent personal assault (sexual assault, physical attack, robbery, mugging), being kidnapped, being taken hostage, terrorist attack, torture, incarceration as a prisoner of war or in a concentration camp, natural or manmade disasters, severe automobile accidents, or being diagnosed with a life-threatening illness. For children, sexually traumatic events may include developmentally inappropriate sexual experiences without threatened or actual violence or injury. Witnessed events include, but are not limited to, observing the serious injury or unnatural death of another person due to violent assault, accident, war, or disaster or unexpectedly witnessing a dead body or body parts. Events experienced by others that are learned about include, but are not limited to, violent personal assault, serious accident, or serious injury experienced y a family member or a close friend; learning about the sudden, unexpected death of a family member or a close friend; or learning that one's child has a life threatening disease. The disorder may be especially sever or long lasting when the stressor is of human design (e.g., torture, rape). the likelihood of developing this disorder may increase as the intensity of and physical proximity to the stressor increase.

The traumatic event can be reexperienced in various ways. Commonly the person has recurrent and intrusive recollections of the event (Criterion B1) or recurrent distressing dreams during which the event can be replayed or otherwise represented (Criterion B2). In rare instances, the person experiences dissociative states that last from a few seconds to several hours, or even days, during which components of the event are relived and the person behaves as though experiencing the event at that moment (Criterion B3). These episodes, often referred to as "flashbacks," are typically brief but can be associated with prolonged distress and heightened arousal. Intense psychological distress (Criterion B4) or physiological reactivity (Criterion B5) often occurs when the person is exposed to triggering events that resemble or symbolize an aspect of the traumatic event (e.g., anniversaries of the traumatic event; cold, snowy weather or uniformed guards for survivors of death camps in cold climates; hot, humid weather for combat veterans of the South Pacific; entering any elevator for an woman who was reaped in an elevator).

Stimuli associated with the trauma are persistently avoided. The person commonly makes deliberate efforts to avoid thoughts, feelings, or conversations about the traumatic event (Criterion C1) and to avoid activities, situations, or people who around recollections of it (Criterion C2). This avoidance of reminders may include amnesia for an important aspect of the traumatic event (Criterion C3). Diminished responsiveness to the external work, referred to as "psychic numbing" or "emotional anesthesia," usually begins soon after the traumatic event. The individual may complain of having markedly diminished interest or participation in previously enjoyed activities (Criterion C4), of feeling detached or estranged from other people (Criterion C5), or of having markedly reduced ability to feel emotions (especially those associated with intimacy, tenderness and sexuality) (Criterion C6). The individual may have a sense of a foreshortened future (e.g., not expecting to have a career, marriage, children, or a normal life span) (Criterion C7).

The individual has persistent symptoms of anxiety or increased arousal that were not present before the trauma. these symptoms may include difficulty falling or staying asleep that may be to recurrent nightmares during which the traumatic event is relived (Criterion D1), hypervigilance (Criterion D4), and exaggerated startle response (Criterion D5). Some individuals report irritability or outburst of anger (Criterion D2) or difficulty concentrating or completing tasks (Criterion D3)."

Dissociative Identity Disorder (DID)

"The essential feature of Dissociative identity Disorder is the presence of two or more distinct identities or personality states (Criterion A) that recurrently take control of behavior (Criterion B). There is an inability to recall important personal information, the extent of which is too great to be explained by ordinary forgetfulness (Criterion C). The disturbance is not due tot eh direct physiological effects of a substance or a general medical condition (Condition D.). In children, the symptoms cannot be attributed to imaginary playmates or other fantasy play.

Dissociative Identity Disorder reflects a failure to integrate various aspects of identity, memory, and consciousness. Each personality state may be experienced as if it has a distinct personal history, self-image, and identity, including a separate name. Usually there is a primary identity that carries the individual's given name and is passive, dependent, guilty, and depressed. The alternate identities frequently have different names and characteristics that contrast with the primary identity (e.g., are hostile, controlling, and self-destructive). Particular identities may emerge in specific circumstances and may differ in reported age and gender, vocabulary, general knowledge, or predominant affect. Alternate identities are experienced as taking control in sequence, ore at the expense of the other, and may deny knowledge of one another, be critical of one another, or appear to be in open conflict. Occasionally, one or more powerful identities allocate time to the others. Aggressive or hostile identities may at times interrupt activities or place the others in uncomfortable situations.

Individuals with this disorder experience frequent gaps in memory for personal history, both remote and recent. The amnesia is frequently asymmetrical. The more passive identities tend to have more constricted memories, whereas the more hostile, controlling, or "protector" identities have more complete memories. An identity that is not in control may nonetheless gain access to consciousness by producing auditory or visual hallucinations (e.g., a voice giving instructions). Evidence of amnesia may be uncovered by reports from others who have witnessed behavior that is disavowed by the individual or by the individual's own discoveries (e.g., finding items of clothing at home that the individual cannot remember having bought). There may be loss of memory not only for recurrent periods of time, but also an overall loss of biographical memory for some extended period of childhood, adolescence, or even adulthood. Transitions among identities are often triggered by psychosocial stress. The time required to switch from one identity to another is usually a matter of seconds, but, less frequently, may b gradual. Behavior that may be frequently associated with identity switches include rapid blinking, facial changes, changes in voice or demeanor, or disruption in the individual's train of thoughts. The number of identities reported ranges from 2 to more than 100. Half of reported cases include the individuals with 10 or fewer identities."

"Eye Movement Desensitization and Reprocessing (EMDR)1 integrates elements of many effective psychotherapies in structured protocols that are designed to maximize treatment effects. These include psychodynamic, cognitive behavioral, interpersonal, experiential, and body-centered therapies2. EMDR is an information processing therapy and uses an eight phase approach.

During EMDR1 the client attends to past and present experiences in brief sequential doses while simultaneously focusing on an external stimulus. Then the client is instructed to let new material become the focus of the next set of dual attention. This sequence of dual attention and personal association is repeated many times in the session.

Eight Phases of Treatment

The first phase is a history taking session during which the therapist assesses the client's readiness for EMDR and develops a treatment plan. Client and therapist identify possible targets for EMDR processing. These include recent distressing events, current situations that elicit emotional disturbance, related historical incidents, and the development of specific skills and behaviors that will be needed by the client in future situations.

During the second phase of treatment, the therapist ensures that the client has adequate methods of handling emotional distress and good coping skills, and that the client is in a relatively stable state. If further stabilization is required, or if additional skills are needed, therapy focuses on providing these. The client is then able to use stress reducing techniques whenever necessary, during or between sessions. However, one goal is not to need these techniques once therapy is complete.

In phase three through six, a target is identified and processed using EMDR procedures. These involve the client identifying the most vivid visual image related to the memory (if available), a negative belief about self, related emotions and body sensations. The client also identifies a preferred positive belief. The validity of the positive belief is rated, as is the intensity of the negative emotions.

After this, the client is instructed to focus on the image, negative thought, and body sensations while simultaneously moving his/her eyes back and forth following the therapist's fingers as they move across his/her field of vision for 20-30 seconds or more, depending upon the need of the client. Athough eye movements are the most commonly used external stimulus, therapists often use auditory tones, tapping, or other types of tactile stimulation. The kind of dual attention and the length of each set is customized to the need of the client. The client is instructed to just notice whatever happens. After this, the clinician instructs the client to let his/her mind go blank and to notice whatever thought, feeling, image, memory, or sensation comes to mind. Depending upon the client's report the clinician will facilitate the next focus of attention. In most cases a client-directed association process is encouraged. This is repeated numerous times throughout the session. If the client becomes distressed or has difficulty with the process, the therapist follows established procedures to help the client resume processing. When the client reports no distress related to the targeted memory, the clinician asks him/her to think of the preferred positive belief that was identified at the beginning of the session, or a better one if it has emerged, and to focus on the incident, while simultaneously engaging in the eye movements. After several sets, clients generally report increased confidence in this positive belief. The therapist checks with the client regarding body sensations. If there are negative sensations, these are processed as above. If there are positive sensations, they are further enhanced.

In phase seven, closure, the therapist asks the client to keep a journal during the week to document any related material that may arise and reminds the client of the self-calming activities that were mastered in phase two.

The next session begins with phase eight, re-evaluation of the previous work, and of progress since the previous session. EMDR treatment ensures processing of all related historical events, current incidents that elicit distress, and future scenarios that will require different responses. The overall goal is produce the most comprehensive and profound treatment effects in the shortest period of time, while simultaneously maintaining a stable client within a balanced system.

After EMDR processing, clients generally report that the emotional distress related to the memory has been eliminated, or greatly decreased, and that they have gained important cognitive insights. Importantly, these emotional and cognitive changes usually result in spontaneous behavioral and personal change, which are further enhanced with standard EMDR procedures." www.emdr.com

__________________

Major Depressive Disorder

“Diagnostic Features

The essential feature of Major Depressive Disorder is a clinical course that is characterized by one or more Major Depressive Episodes without a history of Manic, Mixed, or Hypomanic Episodes (Criteria A and C). Episodes of Substance-Induced Mood Disorder (due to the direct physiological effects of a drug of abuse, a medication, or toxin exposure) or of Mood Disorder Due to a General Medical Condition do not count toward a diagnosis of Major Depressive Disorder. In addition, the episodes must not be better accounted for by Schizoaffective Disorder and are not superimposed on Schizophrenia, Schizophreniform Disorder, Delusional Disorder, or Psychotic Disorder Not Otherwise Specified (Criterion B).

The fourth digit in the diagnostic code for Major Depressive Disorder indicates whether it is a Single Episode (used only for first episodes) or Recurrent. It is sometimes difficult to distinguish between a single episode with waxing and waning symptoms and two separate episodes. For purposes of this manual, an episode is considered to have ended when the full criteria for eh Major Depressive Episode have not been met for at least 2 consecutive months. During this 2-month period, there is either complete resolution of symptoms or the presence of depressive symptoms that no longer meet the full criteria for a Major Depressive Episode (In Partial Remission).

The fifth digit in the diagnostic code for Major Depressive Disorder indicates the current state of the disturbance. If the criteria for a Major Depressive Disorder are met, the severity of the episode is notes as Mild, Moderate, Severe Without Psychotic Features, or Severe With Psychotic Features. If the criteria for a Major Depressive Episode are not currently met, the fifth digit is used to indicate whether the disorder is In Partial Remission or In Full Remission.

If Manic, Mixed, or Hypomanic Episodes develop in the course of Major Depressive Disorder, the diagnosis is changed to a Bipolar Disorder. However, if manic or hypomanic symptoms occur as a direct effect of antidepressant treatment, use of other medications, substance use, or toxin exposure, the diagnosis of Major Depressive Disorder remains appropriate and an addition diagnosis of Substance-induced Mood Disorder, With Manic features (or With Mixed Features), should be noted. Similarly, if manic or hypomanic symptoms occur as a direct effect of a general medical condition, the diagnosis of Major Depressive Disorder remains appropriate and an additional diagnosis of Mood Disorder Due to a General Medical Condition, With Manic Features (or With Mixed Features), should be noted.” p. 369

“Course

Major Depressive Disorder may begin at any age, with an average age at onset in the mid-20s. Epidemiological data suggest that the age at onset is decreasing for those born more recently. The course of Major Depressive Disorder, Recurrent, is variable. Some people have isolated episodes that are separated by many years without any depressive symptoms, whereas others have clusters of episodes, and still others have increasingly frequent episodes as they grow older. Some evidence suggests that the periods of remission generally last longer early in the course of the disorder. The number of prior episodes predicts the likelihood of developing a subsequent Major Depressive Episode. At least 60% of individuals with Major Depresssive Disorder, Single Episode, can be expected to have a second episode. Individuals who have had tow episodes have a 70% chance of having a third, and individuals who have had three episodes have a 90% chance of having a fourth. About 5%-10% of individuals with Major Depressive Disorder, single Episode, subsequently develop a Manic Episode (i.e., develop Bipolar I Disorder).

Major Depressive Episodes may end completely (in about two-thirds of cases), or only partially or not at all (in about one-third of cases). For individuals who have only partial remission, there is a greater likelihood of developing additional episodes and of continuing the pattern of partial interepisode recovery. The longitudinal course specifiers With Full Interepisode Recovery and Without Full Interepisode Recovery may therefore have prognostic value. A number of individuals have pre-existing Dysthymic Disorder prior to the onset of Major Depressive Disorder, single Episode. Some evidence suggests that these individuals are more likely to have additional Major Depressive Episodes, have poorer interepisode recovery, and may require additional acute-phase treatment and a longer period of continuing treatment to attain and maintain a more thorough and longer-lasting euthymic state.

Follow-up naturalistic studies suggested that 1 year after the diagnosis of a major Depressive Episode, 40% of individuals still have symptoms that are sufficiently severe to meet criteria for a full Major Depressive Episode, roughly 20% continue to have some symptoms that no longer meet full criteria for a Major Depressive Episode (i.e., major Depressive Disorder, In Partial Remission), and 40% have no Mood Disorder. The severity of the initial Major Depressive Episode appears to predict persistence. Chronic general medical conditions are also a risk factor for more persistent episodes.

Episodes of Major Depressive Disorder often follow a severe psychosocial stressor, such as the death of a loved one or divorce. Studies suggest that psychosocial events 9stressors) may play a more significant role in the precipitation of the first or second episodes of Major Depressive Disorder and may play less of a role in the onset of subsequent episodes. Chronic general medical conditions and Substance Dependence (particularly Alcohol or Cocaine Dependence) may contribute to the onset or exacerbation of Major Depressive Disorder.

It is difficult to predict whether the first episode of a Major Depressive Disorder in a young person will ultimately evolve into a Bipolar Disorder. Some data suggest that the acute onset of severe depression, especially with psychotic features and psychomotor retardation, in a young person without prepubertal psychopathology is more likely to predict a bipolar disorder. A family history of Bipolar Disorder may also be suggestive of subsequent development of Bipolar Disorder.” p. 372-373

The essential feature
of Major Depressive Disorder is a clinical course that is
characterized by one or more Major Depressive Episodes without a
history of Manic, Mixed, or Hypomanic Episodes (Criteria A and
C). Episodes of Substance-Induced Mood Disorder (due to the
direct physiological effects of a drug of abuse, a medication,
or toxin exposure) or of Mood Disorder Due to a General Medical
Condition do not count toward a diagnosis of Major Depressive
Disorder. In addition, the episodes must not be better
accounted for by Schizoaffective Disorder and are not
superimposed on Schizophrenia, Schizophreniform Disorder,
Delusional Disorder, or Psychotic Disorder Not Otherwise
Specified (Criterion B).

The
fourth digit in the diagnostic code for Major Depressive
Disorder indicates whether it is a Single Episode (used only for
first episodes) or Recurrent. It is sometimes difficult to
distinguish between a single episode with waxing and waning
symptoms and two separate episodes. For purposes of this
manual, an episode is considered to have ended when the full
criteria for eh Major Depressive Episode have not been met for
at least 2 consecutive months. During this 2-month period,
there is either complete resolution of symptoms or the presence
of depressive symptoms that no longer meet the full criteria for
a Major Depressive Episode (In Partial Remission).

The fifth
digit in the diagnostic code for Major Depressive Disorder
indicates the current state of the disturbance. If the criteria
for a Major Depressive Disorder are met, the severity of the
episode is notes as Mild, Moderate, Severe Without Psychotic
Features, or Severe With Psychotic Features. If the criteria
for a Major Depressive Episode are not currently met, the fifth
digit is used to indicate whether the disorder is In Partial
Remission or In Full Remission.

If Manic,
Mixed, or Hypomanic Episodes develop in the course of Major
Depressive Disorder, the diagnosis is changed to a Bipolar
Disorder. However, if manic or hypomanic symptoms occur as a
direct effect of antidepressant treatment, use of other
medications, substance use, or toxin exposure, the diagnosis of
Major Depressive Disorder remains appropriate and an addition
diagnosis of Substance-induced Mood Disorder, With Manic
features (or With Mixed Features), should be noted. Similarly,
if manic or hypomanic symptoms occur as a direct effect of a
general medical condition, the diagnosis of Major Depressive
Disorder remains appropriate and an additional diagnosis of Mood
Disorder Due to a General Medical Condition, With Manic Features
(or With Mixed Features), should be noted.” p. 369

“Course

Major Depressive Disorder may begin at any
age, with an average age at onset in the mid-20s.
Epidemiological data suggest that the age at onset is decreasing
for those born more recently. The course of Major Depressive
Disorder, Recurrent, is variable. Some people have isolated
episodes that are separated by many years without any depressive
symptoms, whereas others have clusters of episodes, and still
others have increasingly frequent episodes as they grow older.
Some evidence suggests that the periods of remission generally
last longer early in the course of the disorder. The number of
prior episodes predicts the likelihood of developing a
subsequent Major Depressive Episode. At least 60% of
individuals with Major Depresssive Disorder, Single Episode, can
be expected to have a second episode. Individuals who have had
tow episodes have a 70% chance of having a third, and
individuals who have had three episodes have a 90% chance of
having a fourth. About 5%-10% of individuals with Major
Depressive Disorder, single Episode, subsequently develop a
Manic Episode (i.e., develop Bipolar I Disorder).

Major
Depressive Episodes may end completely (in about two-thirds of
cases), or only partially or not at all (in about one-third of
cases). For individuals who have only partial remission, there
is a greater likelihood of developing additional episodes and of
continuing the pattern of partial interepisode recovery. The
longitudinal course specifiers With Full Interepisode Recovery
and Without Full Interepisode Recovery may therefore have
prognostic value. A number of individuals have pre-existing
Dysthymic Disorder prior to the onset of Major Depressive
Disorder, single Episode. Some evidence suggests that these
individuals are more likely to have additional Major Depressive
Episodes, have poorer interepisode recovery, and may require
additional acute-phase treatment and a longer period of
continuing treatment to attain and maintain a more thorough and
longer-lasting euthymic state.

Follow-up
naturalistic studies suggested that 1 year after the diagnosis
of a major Depressive Episode, 40% of individuals still have
symptoms that are sufficiently severe to meet criteria for a
full Major Depressive Episode, roughly 20% continue to have some
symptoms that no longer meet full criteria for a Major
Depressive Episode (i.e., major Depressive Disorder, In Partial
Remission), and 40% have no Mood Disorder. The severity of the
initial Major Depressive Episode appears to predict
persistence. Chronic general medical conditions are also a risk
factor for more persistent episodes.

Episodes
of Major Depressive Disorder often follow a severe psychosocial
stressor, such as the death of a loved one or divorce. Studies
suggest that psychosocial events 9stressors) may play a more
significant role in the precipitation of the first or second
episodes of Major Depressive Disorder and may play less of a
role in the onset of subsequent episodes. Chronic general
medical conditions and Substance Dependence (particularly
Alcohol or Cocaine Dependence) may contribute to the onset or
exacerbation of Major Depressive Disorder.

It is
difficult to predict whether the first episode of a Major
Depressive Disorder in a young person will ultimately evolve
into a Bipolar Disorder. Some data suggest that the acute onset
of severe depression, especially with psychotic features and
psychomotor retardation, in a young person without prepubertal
psychopathology is more likely to predict a bipolar disorder. A
family history of Bipolar Disorder may also be suggestive of
subsequent development of Bipolar Disorder.” p. 372-373

"The essential feature of Dissociative identity
Disorder is the presence of two or more distinct identities or
personality states (Criterion A) that recurrently take control
of behavior (Criterion B). There is an inability to recall
important personal information, the extent of which is too great
to be explained by ordinary forgetfulness (Criterion C). The
disturbance is not due tot eh direct physiological effects of a
substance or a general medical condition (Condition D.). In
children, the symptoms cannot be attributed to imaginary
playmates or other fantasy play.

Dissociative Identity Disorder reflects a failure
to integrate various aspects of identity, memory, and
consciousness. Each personality state may be experienced as if
it has a distinct personal history, self-image, and identity,
including a separate name. Usually there is a primary identity
that carries the individual's given name and is passive,
dependent, guilty, and depressed. The alternate identities
frequently have different names and characteristics that
contrast with the primary identity (e.g., are hostile,
controlling, and self-destructive). Particular identities may
emerge in specific circumstances and may differ in reported age
and gender, vocabulary, general knowledge, or predominant
affect. Alternate identities are experienced as taking control
in sequence, ore at the expense of the other, and may deny
knowledge of one another, be critical of one another, or appear
to be in open conflict. Occasionally, one or more powerful
identities allocate time to the others. Aggressive or hostile
identities may at times interrupt activities or place the others
in uncomfortable situations.

Individuals with this disorder experience
frequent gaps in memory for personal history, both remote and
recent. The amnesia is frequently asymmetrical. The more
passive identities tend to have more constricted memories,
whereas the more hostile, controlling, or "protector" identities
have more complete memories. An identity that is not in control
may nonetheless gain access to consciousness by producing
auditory or visual hallucinations (e.g., a voice giving
instructions). Evidence of amnesia may be uncovered by reports
from others who have witnessed behavior that is disavowed by the
individual or by the individual's own discoveries (e.g., finding
items of clothing at home that the individual cannot remember
having bought). There may be loss of memory not only for
recurrent periods of time, but also an overall loss of
biographical memory for some extended period of childhood,
adolescence, or even adulthood. Transitions among identities
are often triggered by psychosocial stress. The time required
to switch from one identity to another is usually a matter of
seconds, but, less frequently, may b gradual. Behavior that may
be frequently associated with identity switches include rapid
blinking, facial changes, changes in voice or demeanor, or
disruption in the individual's train of thoughts. The number of
identities reported ranges from 2 to more than 100. Half of
reported cases include the individuals with 10 or fewer
identities."

"The essential feature of Posttraumatic Stress
Disorder us the development of characteristic symptoms following
exposure to an extreme traumatic stressor involving direct
personal experience of an event that involves actual or
threatened death or serious injury, or other threat to one's
physical integrity; or witnessing an event that involves death,
injury, or a threat to the physical integrity of another person;
or learning about unexpected or violent death, serious harm, or
threat of death or injury experienced by a family member or
other close associate (Criteria A1). The person's response to
the event must involve intense fear, helplessness, or horror (or
in children, the response must involve disorganized or agitated
behavior) (Criterion A2). The characteristic symptoms resulting
from the exposure to the extreme trauma include persistent
reexperiencing of the traumatic event (Criterion E), and the
disturbance must cause clinically significant distress or
impairment in social, occupational, or other important areas of
functioning (Criterion F).

Traumatic events that are experienced directly
include, but are not limited to, military combat, violent
personal assault (sexual assault, physical attack, robbery,
mugging), being kidnapped, being taken hostage, terrorist
attack, torture, incarceration as a prisoner of war or in a
concentration camp, natural or manmade disasters, severe
automobile accidents, or being diagnosed with a life-threatening
illness. For children, sexually traumatic events may include
developmentally inappropriate sexual experiences without
threatened or actual violence or injury. Witnessed events
include, but are not limited to, observing the serious injury or
unnatural death of another person due to violent assault,
accident, war, or disaster or unexpectedly witnessing a dead
body or body parts. Events experienced by others that are
learned about include, but are not limited to, violent personal
assault, serious accident, or serious injury experienced y a
family member or a close friend; learning about the sudden,
unexpected death of a family member or a close friend; or
learning that one's child has a life threatening disease. The
disorder may be especially sever or long lasting when the
stressor is of human design (e.g., torture, rape). the
likelihood of developing this disorder may increase as the
intensity of and physical proximity to the stressor increase.

The traumatic event can be reexperienced in
various ways. Commonly the person has recurrent and intrusive
recollections of the event (Criterion B1) or recurrent
distressing dreams during which the event can be replayed or
otherwise represented (Criterion B2). In rare instances, the
person experiences dissociative states that last from a few
seconds to several hours, or even days, during which components
of the event are relived and the person behaves as though
experiencing the event at that moment (Criterion B3). These
episodes, often referred to as "flashbacks," are typically brief
but can be associated with prolonged distress and heightened
arousal. Intense psychological distress (Criterion B4) or
physiological reactivity (Criterion B5) often occurs when the
person is exposed to triggering events that resemble or
symbolize an aspect of the traumatic event (e.g., anniversaries
of the traumatic event; cold, snowy weather or uniformed guards
for survivors of death camps in cold climates; hot, humid
weather for combat veterans of the South Pacific; entering any
elevator for an woman who was reaped in an elevator).

Stimuli associated with the trauma are
persistently avoided. The person commonly makes deliberate
efforts to avoid thoughts, feelings, or conversations about the
traumatic event (Criterion C1) and to avoid activities,
situations, or people who around recollections of it (Criterion
C2). This avoidance of reminders may include amnesia for an
important aspect of the traumatic event (Criterion C3).
Diminished responsiveness to the external work, referred to as
"psychic numbing" or "emotional anesthesia," usually begins soon
after the traumatic event. The individual may complain of
having markedly diminished interest or participation in
previously enjoyed activities (Criterion C4), of feeling
detached or estranged from other people (Criterion C5), or of
having markedly reduced ability to feel emotions (especially
those associated with intimacy, tenderness and sexuality)
(Criterion C6). The individual may have a sense of a
foreshortened future (e.g., not expecting to have a career,
marriage, children, or a normal life span) (Criterion C7).

The individual has persistent symptoms of anxiety
or increased arousal that were not present before the trauma.
these symptoms may include difficulty falling or staying asleep
that may be to recurrent nightmares during which the traumatic
event is relived (Criterion D1), hypervigilance (Criterion D4),
and exaggerated startle response (Criterion D5). Some
individuals report irritability or outburst of anger (Criterion
D2) or difficulty concentrating or completing tasks (Criterion
D3)."

EMDR

Eye Movement Desensitization and Reprocessing

"Eye Movement Desensitization and Reprocessing
(EMDR)1 integrates elements of many effective
psychotherapies in structured protocols that are designed to
maximize treatment effects. These include psychodynamic,
cognitive behavioral, interpersonal, experiential, and
body-centered therapies2. EMDR is an information
processing therapy
and uses an eight phase approach.

During EMDR1 the client attends to
past and present experiences in brief sequential doses while
simultaneously focusing on an external stimulus. Then the client
is instructed to let new material become the focus of the next
set of dual attention.
This sequence of dual attention and personal association is
repeated many times in the session.

Eight Phases of Treatment

The first phase is a history taking session
during which the therapist assesses the client's readiness for
EMDR and develops a treatment plan. Client and therapist
identify possible targets for EMDR processing. These include
recent distressing events, current situations that elicit
emotional disturbance, related historical incidents, and the
development of specific skills and behaviors that will be needed
by the client in future situations.

During the second phase of treatment, the
therapist ensures that the client has adequate methods of
handling emotional distress and good coping skills, and that the
client is in a relatively stable state. If further stabilization
is required, or if additional skills are needed, therapy focuses
on providing these. The client is then able to use stress
reducing techniques whenever necessary, during or between
sessions. However, one goal is not to need these techniques once
therapy is complete.

In phase three through six, a target is
identified and processed using EMDR procedures. These involve
the client identifying the most vivid visual image related to
the memory (if available), a negative belief about self, related
emotions and body sensations. The client also identifies a
preferred positive belief. The validity of the positive belief
is rated, as is the intensity of the negative emotions.

After this, the client is instructed to focus on
the image, negative thought, and body sensations while
simultaneously moving his/her eyes back and forth following the
therapist's fingers as they move across his/her field of vision
for 20-30 seconds or more, depending upon the need of the
client. Athough eye movements
are the most commonly used external stimulus, therapists often
use auditory tones, tapping, or other types of tactile
stimulation. The kind of dual attention and the length of each
set is customized to the need of the client. The client is
instructed to just notice whatever happens. After this, the
clinician instructs the client to let his/her mind go blank and
to notice whatever thought, feeling, image, memory, or sensation
comes to mind. Depending upon the client's report the clinician
will facilitate the next focus of attention. In most cases a
client-directed association process is encouraged. This is
repeated numerous times throughout the session. If the client
becomes distressed or has difficulty with the process, the
therapist follows established procedures to help the client
resume processing. When the client reports no distress related
to the targeted memory, the clinician asks him/her to think of
the preferred positive belief that was identified at the
beginning of the session, or a better one if it has emerged, and
to focus on the incident, while simultaneously engaging in the
eye movements. After several sets, clients generally report
increased confidence in this positive belief. The therapist
checks with the client regarding body sensations. If there are
negative sensations, these are processed as above. If there are
positive sensations, they are further enhanced.

In phase seven, closure, the therapist asks the
client to keep a journal during the week to document any related
material that may arise and reminds the client of the
self-calming activities that were mastered in phase two.

The next session begins with phase eight,
re-evaluation of the previous work, and of progress since the
previous session. EMDR treatment ensures processing of all
related historical events, current incidents that elicit
distress, and future scenarios that will require different
responses. The overall goal is produce the most comprehensive
and profound treatment effects in the shortest period of time,
while simultaneously maintaining a stable client within a
balanced system.

After EMDR processing, clients generally report
that the emotional distress related to the memory has been
eliminated, or greatly decreased, and that they have gained
important cognitive insights. Importantly, these emotional and
cognitive changes usually result in spontaneous behavioral and
personal change, which are further enhanced with standard EMDR
procedures." www.emdr.com